Basic ICD10 CMPCS Coding 2013 Edition Chapter 22
Basic ICD-10 -CM/PCS Coding 2013 Edition Chapter 22 A: Injury (S 00–T 34) © 2013
Learning Objectives • Review the chapter’s learning objectives and key terms • Many different injuries are described in this chapter with individual definitions and rules for coding • At the conclusion of this chapter, what must you know about the coding of traumatic injuries and related procedures? © 2013
ICD-10 -CM Chapter 19 Injury, Poisoning and Certain Other Consequences of External Cause, S 00–T 34, Codes to Describe Injuries • The Injury portion of Chapter 19 includes the following blocks: S 00–S 09 Injuries to the head S 10–S 19 Injuries to the neck S 20–S 29 Injuries to the thorax S 30–S 39 Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitalia o S 40–S 49 Injuries to the shoulder and upper arm o S 50–S 59 Injuries to the elbow and forearm o o © 2013
ICD-10 -CM Chapter 19 Injury, Poisoning and Certain Other Consequences of External Cause, S 00–T 34, Codes to Describe Injuries • The Injury portion of Chapter 19 includes the following blocks (continued): S 60–S 69 Injuries to the wrist, hand fingers S 70–S 79 Injuries to the hip and thigh S 80–S 89 Injuries to the knee and lower leg S 30–S 39 Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitalia o S 90–S 99 Injuries to the ankle and foot o o © 2013
ICD-10 -CM Chapter 19 Injury, Poisoning and Certain Other Consequences of External Cause, S 00–T 34, Codes to Describe Injuries • The Injury portion of Chapter 19 includes the following blocks (continued): o T 07 Injuries involving multiple body regions o T 14 Injury of unspecified body region o T 15–T 19 Effects of foreign body entering through natural orifice o T 20–T 25 Burns and corrosions of external body surface specified by site © 2013
ICD-10 -CM Chapter 19 Injury, Poisoning and Certain Other Consequences of External Cause, S 00–T 34, Codes to Describe Injuries • The Injury portion of Chapter 19 includes the following blocks (continued): o T 26–T 28 Burns and corrosions confined to eye and internal organs o T 30–T 32 Burns and corrosions of multiple and unspecified body regions o T 33–T 34 Frostbite © 2013
ICD-9 -CM Chapter 19 Injury, Poisoning and Certain Other Consequences of External Cause, S 00–T 34, Describe Injuries • Specific types of injuries are arranged by body region beginning with the head and concluding with the ankle and foot • This results in the groupings of injury types under the site where it occurred © 2013
ICD-9 -CM Chapter 19 Injury, Poisoning and Certain Other Consequences of External Cause, S 00–T 34, Describe Injuries • The listing of conditions that follow the site are: o o o o o Superficial injury Open wound Fracture Dislocation and sprain Injury of nerves Injury of blood vessels Injury of muscle and tendon Crushing injury Traumatic amputation Other and unspecified injuries © 2013
Coding Instructional Notes for ICD-10 -CM Chapter 19 • At beginning of chapter 19 includes notes: o Use secondary code(s) from chapter 20, External causes of morbidity, to indicate cause of injury o Codes within the T section that include the external cause do not require an additional external cause code o ICD-10 -CM contains a note under the different categories of open wounds to direct the coder to code also any associated wound infection © 2013
Coding Instructional Notes for ICD-10 -CM Chapter 19 • Most categories in chapter 19 have 7 th characters that identify the encounter o A = Initial Encounter o D = Subsequent Encounter o S = Sequela • 7 th characters for fractures extensions are unique to the type of fracture and episode of care © 2013
Coding Guidelines for ICD-10 -CM Chapter 19 • Chapter-specific guidelines of ICD-10 -CM address: o Application of 7 th characters o Coding of injuries including superficial injuries and primary injury with damage to nerves/blood vessels o Coding of traumatic fractures including initial vs subsequent encounter for fractures, multiple fractures sequencing © 2013
Coding Guidelines for ICD-10 -CM Chapter 19 • Chapter-specific guidelines of ICD-10 -CM address (continued) : o Coding of burns and corrosions including sequencing of burn and related condition codes, burns of the same local site, nonhealing burns, infected burn, assign separate codes for each burn site, burns and corrosions classified according to extent of body surface involved, encounters for treatment of sequela of burns, sequelae with a late effect code and current burn and use of an external cause code with burns and corrosions © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • Alphabetic Index classifies injuries according to the type of injury with subterms under the general type of injury to identify the anatomical site © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • ICD-10 -CM uses a placeholder character “x” in certain codes to allow for future expansions • For example, S 01. 01 x. A for an initial encounter for care of a laceration without foreign body of scalp requires the sixth character to have the placeholder “x” to allow for the addition of the seventh character to indicate the initial encounter of care © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • Separate ICD-10 -CM codes are assigned for each injury unless there is a combination code available. • However, some combination codes should not be assigned, for example, code T 07, Unspecified multiple injuries, should not be assigned in an inpatient setting if at all possible. It should only be used if no more specific information is available from the provider. © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • The code for the most serious injury is sequenced first. The physician documents what is the most serious injury in a patient with multiple injuries • If the patient has superficial injuries associated with a more serious injury at the same site, the code for the superficial injuries such as contusions and abrasions are not coded. The superficial injuries are expected to be present with a more serious injury © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • Three seventh character values are used for most of the categories with the exception of fractures. • Seventh character of A o Used to identify the initial encounter of care o Initial encounter is when the patient is receiving active treatment for the injury, that is, surgical treatment, emergency department encounters and evaluation and treatment by a new physician © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • Seventh character of D o Used to identify the subsequent encounter of care o Subsequent encounter is used for visits after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase o Examples include cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits following injury treatment © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • Seventh character of S o Used to identify a sequela of an injury. These are complications or condition that arise as a direct result of an injury. o When using 7 th character S, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. o The S character is added only to the injury code to identify the injury responsible for the sequela o The specific type of sequela condition is sequenced first, followed by the injury code © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • Seventh characters o The aftercare Z codes should not be used for aftercare for injuries o Instead, to report the aftercare of an injury, the coder should assign the acute injury code with the seventh character D for subsequent encounter © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • Traumatic fractures are coded to the specific sites of the fractures • A fracture that is not indicated as open or closed is coded as a closed fracture • A fracture that is not indicated as a displaced fracture or a nondisplaced fracture is coded to a displaced fracture © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • Closed fracture is when the bone breaks but there is no puncture or open wound in the skin • Open fracture is when the bone breaks through the skin even though it may fall back into the wound and may or may not be visible through the wound. It may be also be called a comminuted fracture © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • Displaced fracture is a bone that breaks into two or more parts and the two ends of the bone are out of place and need to be realigned • Nondisplaced fracture is when the fracture of the bone occurs with a crack either part way or all the way through the bone but the bone remains in alignment © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • Other terminology to describe a fracture are • • Comminuted Greenstick Impacted Oblique Pathological (which is not traumatic) Stress (which is not traumatic) Transverse © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • Fracture codes include 7 th characters to identify the episode of care : A—Initial encounter for closed fracture B—Initial encounter for open fracture D—Subsequent encounter for fracture with routine healing G—Subsequent encounter for fracture with delayed healing K—Subsequent encounter for fracture with nonunion P—Subsequent encounter for fracture with malunion S—Sequelae © 2013
Coding of Injuries in ICD-10 -CM Chapter 19 • Open fracture codes include 7 th characters: B—Initial encounter for open fracture type I or II, NOS C—Initial encounter for open fracture type IIIA, IIIB, or IIIC E—Subsequent encounter for open fracture type I or II with routine healing F—Subsequent encounter for open fracture type IIIA, IIIB, IIIC with routine healing H—Subsequent encounter for open fracture type I or II with delayed healing J—Subsequent encounter for open fracture type IIIA, IIIB, IIIC with delayed healing © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Open fracture codes include 7 th characters: M—Subsequent encounter for open fracture type I or II with nonunion N—Subsequent encounter for open fracture type IIIA, IIIB, IIIC with nonunion Q—Subsequent encounter for open fracture type I or II with malunion R—Subsequent encounter for open fracture type IIIA, IIIB, IIIC with malunion © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Multiple fractures o Coder should assign separate codes for each fracture unless a combination code is assigned o Combination category codes for multiple fractures are provided when the documentation states multiple fractures at one site but without specific details © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Dislocation and Subluxation o Dislocation is the displacement of a bone from its joint o Subluxation is an incomplete dislocation with the contact between the joint surfaces remaining in place o Both coded to the specific site of the dislocation o Main term used in the Index is dislocation or subluxation o Each code requires a seventh character for initial (A), subsequent (D) or sequela (S) to identify episode of care © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Dislocation and Subluxation o Pathological dislocations are not the same as traumatic o May be documented as a recurrent dislocation o Once a dislocation of a joint has occurred, it takes less effort to produce another dislocation of the same joint o Only the initial occurrence of the joint dislocation is coded to the injury code o All subsequent dislocations of the same joint are coded as recurrent dislocations © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Sprains and Strains o Sprain is an injury of the supporting ligaments of a joint o Strain is overstretching or overexertion of some part of the musculature. A strain can be a partial tear in the muscle attached to a bone. • Traumatic sprains are coded to the specific site • Alphabetic main term is “Sprain” by site • Each sprain code requires a 7 th character to identify the encounter © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Traumatic strains may be a traumatic injury • Alphabetic main term is “Strain” with subterms for a limited number of sites that direct the coder to the injury chapter • Injuries to muscles and tendons are coded to the specific site, • Alphabetic main term is Injury, muscle (and tendon) or Injury, tendon (see also Injury, muscle) • Each code requires 7 th character for encounter © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Intracranial Injury, Excluding Those with Skull Fracture o Various forms of traumatic brain injury o Fourth-character subterms identify the specific intracranial injuries of • • Concussion Traumatic cerebral edema Diffuse traumatic brain injury Focal traumatic brain injury Epidural hemorrhage Traumatic subarachnoid hemorrhage Other and unspecified intracranial injuries © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Intracranial Injury, Excluding Those with Skull Fracture (continued) o Sixth characters for the codes in category S 06 identify whether the patient did or did not have a loss of consciousness with information about the length of time of the unconsciousness and whether or not the patient returned to preexisting conscious level or if the patient died due to the brain injury or other cause prior to regaining consciousness o Code also notes remind the code to code associated open wound of head or skull fracture o Excludes 1 note under S 06 states head injury NOS is coded to S 09. 90 for the diagnosis of “head injury” without the specificity of an intracranial injury © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Injury to Internal Organs o Main term in the Alphabetic Index is Injury, internal with subterms for anatomic sites or internal cavities such as intraabdominal o Instructional notes appear with the internal injury codes to code associated conditions, such as open wound, traumatic hemothorax, etc. o All codes require the use of the 7 th characters of A, D, or S to identify the encounter of care or the sequela of an injury © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Open Wound o Open wound is an injury of the soft tissue parts associated with rupture of the skin o Open wounds may be animal bites, avulsions, cuts, lacerations, puncture wounds and traumatic amputation o Open wound may be a penetrating wound which involves the passage of an object through tissue that leaves and entrance and exit, as in the case of a knife wound or gunshot wound o Open wounds are classified by site o Instructional codes appear to code also any associated injury to nerve, injury to muscle and tendon, intracranial injury, spinal cord injury or associated wound infection as well as injury to internal organs © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Burns and Corrosions o Burns are caused by a heat source such as fire, electricity, radiation, etc o Corrosions are burns due to a chemical o Current burns are classified by depth, extent, and by agent or external cause o Depth of burns are classified as o First degree as the least severe damage to epidermis or outer layer of skin o Second degree involves the epidermis and dermis with blisters o Third degree is the most severe and includes all three layers of skin: epidermis, dermis and subcutaneous © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Burns and Corrosions o When there is treatment of multiple external burns, the site of the burn with the highest degree is coded and sequenced first o Additional codes are used for additional sites with lesser degree burns o When patient has both external and internal burn, either type of burn could be coded and sequenced first depending on the circumstances of the admission or encounter o When the patient is admitted with burns and related injuries such as smoke inhalation or organ failure, the circumstances of the admission will determine the sequencing of the principal diagnosis © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Burns and Corrosions (continued) o When the patient has varying degrees of burns on one site (a single category between T 20–T 28) one code is assigned for the highest degree for that site o If burns exist on multiple sites multiple separate codes are assigned o If a burn is not (non)healing, it is coded as an acute burn for each encounter in which it is treated o If the condition is described as necrosis of burned skin, it is the equivalent of a nonhealing burn o If the burn site is documented as infected, an additional code for the infection is also assigned © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Burns and Corrosions (continued) o Category T 31, Burns classified according to extent of body surface involved is used as the primary code when the site of the burn is unspecified o This category is used as an additional code when the site is specified to report what extent of the body surface is covered and what percent of the body surface is a third-degree burn o Main term in the Alphabetic Index is burn or corrosion o Common sequela of burns are scars on the skin or joint contractures. When this occurs, the sequela condition is coded with a code for the original burn with the seventh character of S. © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Superficial Injury o Contusions are injuries of the soft tissue. The skin is not broken but small vessels or capillaries are ruptured and the result is bleeding into the tissue. When blood is trapped in the interstitial space, the result is a hematoma. o Other superficial injuries are abrasion, blister, external constriction, superficial foreign body, insect bite or other superficial bite of a specific location o Injuries are coded according to the body site where it exists and according to specified laterality of the site with codes for right, left and unspecified side o Main term to be used in Alphabetic Index is Injury, superficial, followed by the body part or by the word for the injury. A 7 th character of A, D, or S is required with the code © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Injury to Blood Vessels, Nerves and Spinal Cord o When a primary injury results in minor damage to peripheral nerves or blood vessels, the code for the primary injury is sequenced first with additional codes for injuries to nerves and/or blood vessels o When the primary or major injury is to the blood vessel or nerve, the code for that injury to the blood vessel or nerve is sequenced first o Injuries to blood vessels may be a minor laceration described as an incomplete transection or a superficial laceration of a vessel. A major laceration of a vessel would be a complete transection or traumatic rupture of the blood vessel © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Injury to Blood Vessels, Nerves and Spinal Cord o Injuries to region of the spinal cord are classified as to the type of injury, such as complete lesion, central cord syndrome, anterior cord syndrome, Brown-Sequard syndrome or other incomplete lesions o Injuries to nerves are classified by the specific nerve involved o Alphabetic Index entries for locating injuries to blood vessels, nerve and spinal cord include: o Injury, blood vessel, by site o Injury, nerve, cranial o Injury, spinal cord by spinal region and then by level © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Injury to Blood Vessels, Nerves and Spinal Cord o Each of these injury codes require a seventh character to identify the initial encounter of care (A), subsequent encounter of care (D), or sequela episode (S) o Instructional notes appear through out the section of codes o Code first any associated intracranial injury o Code any associated open wound o Code any associated fracture o Code any associated transient paralysis o Cranial nerves are coded with the selection of the side or laterality o Spinal cord injuries are coded to the high level of spinal cord injury © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Traumatic Amputation o A traumatic amputation is the loss of a body part as the result of an accident or injury o Amputation that is not identified as partial or complete is coded as a complete amputation o Amputations are coded by site, such as shoulder and upper arm, elbow and forearm, wrist, hand fingers, hip and thigh, lower leg, and ankle and foot o Each code requires the use of the 7 th character to identify whether it is the initial encounter (A), subsequent encounter (D), or sequela of the amputation (S) © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Effects of Foreign Body Entering Through Natural Orifice o These codes do not include foreign body accidentally left in operative wound, foreign body in penetrating wound, residual foreign body in soft tissue or splinter without open wound o Categories for coding of foreign body are body system, with 4 th and 5 th character codes to identify the specific body part where the foreign body was located and 6 th character identifies a complication of the presence of the foreign body if it exists o Main term in the Alphabetic Index is “Foreign body” with the subterm “entering through orifice” o When foreign body is associated with a laceration, main term is “Foreign body” with subterm “in laceration”—see Laceration, by site, with foreign body o Seventh character of A, D or S is required to identify encounter of care © 2013
Coding Injuries in ICD-10 -CM Chapter 19 • Frostbite o Frostbite damages the skin and subcutaneous tissue when the skin is exposed to cold temperatures for a prolonged period or time or extreme cold for a short period of time o Injury of frostbite is classified in ICD-10 -CM according to whether it is superficial frostbite (T 33) or frostbite with tissue necrosis (T 34) o Superficial frostbite includes partial thickness skin loss o More severe frostbite includes necrosis of tissue at the site of the frostbite o The codes include the laterality of the site as well as an unspecified side o The categories for frostbite require the appropriate seventh character for the initial encounter (A), subsequent encounter (D), or for a sequela (S) © 2013
ICD-10 -PCS Procedure Coding for Treatment of Injuries • Coding Fracture Treatment with the following root operations of reposition, insertion or immobilization • Reposition is moving to its normal location or other suitable location all or a portion of a body part. This is the typical fracture or dislocation “reduction” procedure • Insertion is putting in a nonbiological device that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part. Sole objective is to place a device, such as a pin to hold a nondisplaced fracture to allow it to heal © 2013
ICD-10 -PCS Procedure Coding for Treatment of Injuries • Coding Fracture Treatment with the following root operations • Immobilization is limiting or preventing motion of a body region. • An example of this procedure is the placement of a cast or splint to promote healing of a nondisplaced fracture or a dislocation • The approach is always external • The device used may be a splint, cast, brace, or other device • The application of a cast or splint is not coded separately when performed with a fracture reduction or reposition procedure © 2013
ICD-10 -PCS Procedure Coding for Treatment of Injuries • Coding Repair of Laceration • Repair is defined as a root operation to restore, to the extent possible, a body part to its normal anatomical structure and function • Repair is the root operation for suturing lacerations of skin or internal organs • If a repair is performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded • Repair of a laceration of skin always has the approach external for the ICD-10 -PCS code © 2013
Exercises • Practice coding the conditions included in Chapter 19 of ICD-10 -CM for injuries, as well as the procedures used to treat these conditions by completing the review exercises for Chapter 22 A. © 2013
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